nurs 322 exam 4
A client has a new synthetic leg cast for a right fractured tibia. What health teaching will the nurse include before discharge to home? Select all that apply. A. "Elevate your right leg as often as possible to reduce swelling." B. "Report increased pain or burning sensation under your cast." C. "Use ice on the affected leg for the first 24-36 hours." D. "Do not bear weight on the affected leg until instructed to do so." E. "Do not cover the cast when you are in bed; keep it open to air to dry."
A. "Elevate your right leg as often as possible to reduce swelling." B. "Report increased pain or burning sensation under your cast." C. "Use ice on the affected leg for the first 24-36 hours." D. "Do not bear weight on the affected leg until instructed to do so."
Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? Select all that apply. A. "I am so glad this condition will go away permanently." B. "It is important that I do not drive when I have tinnitus." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus." E. "I have found a couple of support groups that I like to attend."
A. "I am so glad this condition will go away permanently." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus."
The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching? A. "I will take this drug at night to prevent nausea." B. "I need a dental checkup before taking the drug." C. "I need to sit up for 30 minutes after taking the drug." D. "I will drink plenty of water after I take the drug."
A. "I will take this drug at night to prevent nausea."
The nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? Select all that apply. A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."
A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."
The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."
A. "If you tend to get angry easily, then your risk for heart disease is higher." C. "Do not eat more calories on a daily basis that you are able to burn." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."
The nurse is admitting a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."
A. "My ankles swell up all the time." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."
The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."
A. "Please roll onto your left side."
A client had a left non-cemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply. A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." C. "Be sure to cross your legs to be more comfortable in a chair." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."
A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."
The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car." C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."
A. "The nitroglycerin should tingle when I put it in my mouth."
The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."
A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."
The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 mm Hg C. Triglycerides 140 mg/dL D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease
A. BMI of 26 D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigarette smoke G. Family history of cardiovascular disease
The nurse is assessing a client with septic shock. What assessment data indicate a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 mm Hg B. Heart rate change from 98 to 76 beats/min C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 mL/hr
A. BP change from 86/50 to 100/64 mm Hg C. Cool and clammy skin D. Petechiae along the gum line
Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm Hg
A. Carotid artery bruit
The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes three to four times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.
A. Denial is common reaction to chest pain. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.
The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach
A. Digoxin therapy daily
Which assessment data are factors that increase the risk for osteoporosis for an older Euro-American female? Select all that apply. A. Drinks 3 to 4 glasses of wine each day B. Sits at a desk all day at her job C. Smokes a pack of cigarettes a day D. Takes a mile-long walk 5 days a week E. Takes 1000 mg acetaminophen for arthritis daily F. Weighs 110 lb (50 kg)
A. Drinks 3 to 4 glasses of wine each day B. Sits at a desk all day at her job C. Smokes a pack of cigarettes a day F. Weighs 110 lb (50 kg)
The nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? Select all that apply. A. Gown B. Gloves C. Mask D. Foot covers E. Goggles
A. Gown B. Gloves
The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 beats/min B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40 mm Hg
A. Heart rate 118 beats/min
The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 mL of bloody drainage in chest tube over 4 hours
A. Heart rate of 50 beats/min
A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output
A. Increasing pallor B. Increasing thirst D. Increasing heart rate E. Increasing respiratory rate H. Decreasing urine output
Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? Select all that apply. A. Joint inflammation B. Subcutaneous nodules C. Severe weight loss D. Fatigue E. Thrombocytosis F. Anorexia
A. Joint inflammation D. Fatigue F. Anorexia
The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness
A. Joint pain
Which supplement will the nurse recommend to a client who wants to enhance eye health? A. Lutein B. Vitamin D C. Magnesium D. Saw palmetto
A. Lutein
A nurse is performing a musculoskeletal assessment on an older adult. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Kyphosis D. Arthritis E. Widened gait F. Decreased joint range of motion
A. Muscle atrophy B. Slowed movement C. Kyphosis D. Arthritis E. Widened gait F. Decreased joint range of motion
Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision
A. Pain C. Tearing D. Photophobia E. Blurred vision
Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0°F E. Pupil that constricts in response to light
A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity
The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased
A. ST changes C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased
Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask client to read the nurse's lips D. Dialogue with the client's caregivers
A. Use pictures and writing
Which client statement affirms that nurse teaching about instillation of multiple different eyedrops has been effective? Select all that apply. A. "It will be very easy for me to instill all of the drops at one time." B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eyedrops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."
B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eyedrops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."
The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."
B. "I need to take potassium supplements with this medication."
Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."
B. "I was nervous last night, but I still remembered to take my warfarin."
The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? Select all that apply. A. "Take the prescribed drug before breakfast each day." B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day." E. "Follow up with lab tests to assess liver function."
B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day."
The nurse is teaching a client's family regarding the diagnosis of septic shock. Which teaching will the nurse include? Select all that apply. A. "The blood cultures will tell us for sure if your loved one has septic shock." B. "The client's change in behavior and lethargy may be associated with septic shock." C. "Antibiotics, as prescribed, will be started within the hour to treat the sepsis." D. "An insulin drip has been started to keep the client's glucose as low as possible." E. "Septic shock is easily treated with multiple antibiotics."
B. "The client's change in behavior and lethargy may be associated with septic shock." C. "Antibiotics, as prescribed, will be started within the hour to treat the sepsis."
A client had an open reduction internal fixation (ORIF) of the right wrist. What health teaching is appropriate for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Report coolness or discoloration of your right hand to your doctor." D. "Don't place any device under the cast to scratch the skin if it itches." E. "Move the fingers of the right hand frequently to promote blood flow."
B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Report coolness or discoloration of your right hand to your doctor." E. "Move the fingers of the right hand frequently to promote blood flow."
A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop
B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop
The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? A. Blood pressure 146/70 mm Hg B. Hematoma developing at insertion site C. Client reports headache pain D. Client reports extreme thirst
B. Hematoma developing at insertion site
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate
B. Muffled heart sounds with the presence of JVD
The nurse is assigned to care for a postoperative client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurse's first action at this time? A. Elevate the surgical leg on a pillow. B. Perform a neurovascular assessment. C. Administer pain medication. D. Call the primary health care provider.
B. Perform a neurovascular assessment.
The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic attack D. Splenic infarction
B. Renal infarction
The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. SjÖgren syndrome
B. Severe weight loss D. Joint deformities E. SjÖgren syndrome
While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.
B. Stop suctioning the patient.
The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube
B. Stop the infusion of heparin
A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes
B. Sudden, severe low back pain and bruising along the flank
A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight
B. Tobacco use D. Diet E. Family history
A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."
C. "I have a bandage on my sternum to collect the drainage."
A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."
C. "I need to take a full course of antibiotics prior to my colonoscopy."
The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."
C. "I'm glad I don't need to change my diet. Salads are my favorite food."
A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long-term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long-term." C. "It takes several days for warfarin to begin working, so both drugs are required for a short time." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."
C. "It takes several days for warfarin to begin working, so both drugs are required for a short time."
Assistive personnel (AP) are assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the AP indicates a need for follow-up by the nurse? A. "The client's surgical knee is very swollen and discolored." B. "The client states that the surgical knee is very painful when moving it." C. "The client's lower leg on the surgical side is painful and red." D. "The client needs assistance with walking to the bathroom."
C. "The client's lower leg on the surgical side is painful and red."
The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.
C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.
Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)? A. 55-year-old client who recently began wearing glasses B. 59-year-old client who has controlled hypertension C. 62-year-old client with hypothyroidism D. 65-year-old client with diabetes
C. 62-year-old client with hypothyroidism
What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.
C. Assess neurovascular assessment in the affected arm.
The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A. Relieve or reduce the client's pain. B. Maintain the client's airway. C. Assess neurovascular status in the surgical foot. D. Apply a hot compress to the surgical area.
C. Assess neurovascular status in the surgical foot.
When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern
C. Cerumen dries and becomes impacted more easily E. Sounds such as f, s, sh, and pa may be more difficult to discern
A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a shoulder injury. What is the nurse's priority when caring for this client? A. Keep the affected arm elevated and immobilized. B. Ensure that the client uses the patient-controlled analgesia (PCA) pump. C. Check the neurovascular status of the affected arm. D. Instruct the client to stay in bed for 24 hours.
C. Check the neurovascular status of the affected arm.
The nurse assesses a client recently diagnosed with metastatic vertebral bone cancer. Which intervention is the priority when caring for this client? A. Consultation with rehabilitative therapy B. Referral to hospice care C. Drug therapy to manage persistent pain D. Oxygen therapy to prevent dyspnea
C. Drug therapy to manage persistent pain
What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? A. Seeing "shooting stars" B. Decrease in central vision C. Gradual loss of visual fields D. Abrupt onset of excruciating pain
C. Gradual loss of visual fields
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus tachycardia B. Sinus bradycardia C. Normal sinus rhythm D. Sinus arrhythmia
C. Normal sinus rhythm
Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? A. Begin chest compressions B. Check carotid pulse C. Notify the Rapid Response Team D. Get the crash cart/AED E. Provide rescue breaths
C. Notify the Rapid Response Team D. Get the crash cart/AED B. Check carotid pulse A. Begin chest compressions E. Provide rescue breaths
The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What laboratory value will the nurse anticipate? A. pH 7.51 B. PaO 2 106 mm Hg C. PaCO 2 49 mm Hg D. Lactate 0.4 mmol/L
C. PaCO 2 49 mm Hg
The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.
C. Place the client in a high-Fowler position.
What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with Ménière disease? Select all that apply. A. Reducing activity can reduce frequency of episodes. B. Episodes will eventually decrease in severity and number. C. Reducing sodium, caffeine, and alcohol intake can be beneficial. D. The only treatment that is effective is to undergo labyrinthectomy. E. When moving from sitting to standing, be cautious and take your time.
C. Reducing sodium, caffeine, and alcohol intake can be beneficial. E. When moving from sitting to standing, be cautious and take your time.
The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance? A. Blood pressure 144/79 mm Hg B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 lb in the past week D. Generalized edema in the lower extremities
C. Weight increase of 9 lb in the past week
What is the appropriate nursing response when a 66-year-old healthy client asks how often a visit to the eye care provider is recommended? A. "Annually." B. "Every 6 months." C. "Only if you have vision problems." D. "Every 1-2 years if you have no eye problems."
D. "Every 1-2 years if you have no eye problems."
The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day." B. "I will restrict my intake of daily dietary lean protein." C. "I am only going to drink one cup of coffee to start my day." D. "I will drink a glass of low-fat milk with my breakfast."
D. "I will drink a glass of low-fat milk with my breakfast."
The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."
D. "I'll start to exercise gradually, stopping when I have pain."
A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?"
D. "On a scale of 0 to 10, how would you rate your pain?"
When caring for four clients, which client does the nurse report to the health care provider who should not receive an otoscopic examination? A. 25-year-old with throat and ear pain B. 39-year-old experiencing dizziness C. 46-year-old who has type 2 diabetes D. 60-year-old experiencing delirium
D. 60-year-old experiencing delirium
Which serum laboratory finding is of concern for the nurse and should be reported to the primary health care provider? A. Calcium = 9 mg/dL (2.10 mmol/L) B. Phosphorus = 4.5 mg/dL (1.45 mmol/L) C. Lactate dehydrogenase = 150 units/L (150 IU/L) D. Alkaline phosphatase = 210 units/L (210 IU/L)
D. Alkaline phosphatase = 210 units/L (210 IU/L)
The nurse is caring for a client with hypovolemic shock who is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large-bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.
D. Apply direct pressure to the area of overt bleeding.
A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.
D. Assess the client and check lead placement.
What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Turn off the hearing aid when not using it. B. Immerse the ear mold in alcohol to fully clean it. C. Store the hearing aid in a warm, humid bathroom when not in use. D. Avoid using hair spray, makeup, and personal care products around the device.
D. Avoid using hair spray, makeup, and personal care products around the device.
The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking
D. History of smoking
The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99°F (37.2°C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.
D. Serum lactate and serum potassium levels are declining.
The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Venous thromboembolism
D. Venous thromboembolism
1. A nurse is caring for a male client who has peripheral vascular disease and is taking dietary supplements and has a new prescription for warfarin (Coumadin). The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.) a) Saw palmetto b) Echinacea c) Glucosamine d) Black cohosh e) Gingko biloba
a) Saw palmetto c) Glucosamine e) Gingko biloba
1. A nurse is assessing a client who receives chlorothiazide sodium (Diuril). Which of the following is a sign of hypokalemia? a) Shallow respirations b) Hypertensive crisis c) Diarrhea d) Hyperflexion
a) Shallow respirations
1. While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing issues is of greatest priority in the client's care? a. Impaired tissue perfusion b. Alteration in body image c. Alteration in activity tolerance d. Impaired skin integrity
a. Impaired tissue perfusion
1. A nurse is caring for a client who has a cast in place for a fractured tibia. Of the following, which nursing action is the priority immediately after the provider has applied the cast? a. Checking capillary refill b. Discussing cast care c. Managing pain d. Performing range of motion
a. Checking capillary refill
1. A nurse in the emergency department is caring for a client who reports chest pressure, indigestion, fatigue, and occasional shortness of breath. Which of the following laboratory tests will provide the most specific indication of whether or not the client has had a myocardial infarction (MI)? a. Troponin I b. Myoglobin c. Creatine kinase d. Aspartate aminotransferase (AST)
a. Troponin I
1. A nurse is caring for a client who has a blood pressure of 156/98. Which of the following findings would the client manifest with Stage 1 hypertension? a. Vertigo b. Uremia c. Blurred vision d. Dyspnea
a. Vertigo
1. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the following findings should the nurse expect? a) Decreased brain natriuretic peptide (BNP). b) Elevated central venous pressure (CVP). c) Decreased pulmonary pressure. d) Increased urinary output.
b) Elevated central venous pressure (CVP).
1. A nurse caring for a client who has a femur fracture suspects fat embolism syndrome. Which of the following findings is the nurse's earliest warning that this complication is developing? a. Petechiae b. Confusion c. Tachycardia d. Crackles
b. Confusion
1. A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) a. Genetic predisposition b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking
b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking
1. A nurse is caring for a client in the critical care unit following a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion? a. Widening pulse pressure. b. Muffled heart sounds. c. Elevating systolic blood pressure. d. Decreasing venous pressure.
b. Muffled heart sounds.
1. A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight? a. Change in temperature of the toes. b. Pallor of the toes. c. Edema of the toes. d. Inability to move toes.
b. Pallor of the toes.
A nurse is caring for a client hospitalized for an open reduction of a fractured femur and application of a cast. The most important nursing action for the care of this client is to a) medicate the client for pain. b) use the palms of the hands when moving an extremity with a wet cast. c) perform neurovascular checks of the extremities. d) petal the edges of the cast to provide smooth edges.
c) perform neurovascular checks of the extremities.
1. A nurse is assessing a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.) a. Orthopnea b. Headache c. Nausea d. Tachycardia e. Diaphoresis
c. Nausea d. Tachycardia e. Diaphoresis
1. A nurse is caring for a client who enters the emergency department of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction? a. Check the client's blood pressure. b. Auscultate heart tones. c. Perform a 12-lead ECG d. Determine if pain radiates to the left arm.
c. Perform a 12-lead ECG
1. A nurse is taking the history of a client suspected of having cardiovascular disease. Which past illness in the client's history would alert the nurse to the possibility of an abnormality of the heart valves? a. A history of infection with Mycobacterium tuberculosis b. Recurrent viral pneumonia c. Rheumatic fever d. Asthma
c. Rheumatic fever
1. While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities? a. Ventricular depolarization b. Slow repolarization of ventricular Purkinje fibers c. Atrial depolarization d. Early ventricular repolarization
c. Atrial depolarization
1. A client with valvular heart disease is at risk for developing left-sided heart failure. The nurse knows to monitor which of the following parameters to determine if the client has developed this disorder? a. Appetite b. Body weight c. Breath sounds d. Blood pressure
c. Breath sounds
1. A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, shortness of breath and nausea. Which of the following actions should the nurse perform first? a. Administer oxygen. b. Begin ECG monitoring. c. Ensure a patent airway. d. Assess pain using the pain scale (0 to 10).
c. Ensure a patent airway.
1. A nurse is giving discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and receives anticoagulant therapy. Which of the following instructions should the nurse include? a. Applying cool compresses to her legs b. Wearing loose, non-constricting stockings c. Flexing her knees and feet frequently d. Taking an NSAID tablet daily
c. Flexing her knees and feet frequently
1. A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first? a. Attach the leads for a 12-lead ECG. b. Obtain the blood sample. c. Initiate oxygen therapy. d. Insert the IV catheter.
c. Initiate oxygen therapy.
1. A nurse is preparing a client for an echocardiogram the following day. Which of the following instructions should the nurse include about this test? a. It might cause slight discomfort in the chest area. b. It takes about 5 or 10 min. c. It requires lying quietly on one side. d. It is best to have no food or beverages the day of the test.
c. It requires lying quietly on one side.
1. To evaluate a client following cardiac catheterization with a left antecubital insertion site, the nurse should palpate the a. brachial pulse in the left arm. b. brachial pulse in the right arm. c. radial pulse in the left arm. d. radial pulse in the right arm.
c. radial pulse in the left arm.
1. A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? a) The pain usually lasts more than 20 min. b) The pain often radiates to the jaw or the back. c) The pain persists with rest and organic nitrates. d) Exertion and anxiety can trigger the pain.
d) Exertion and anxiety can trigger the pain.
1. A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the affected arm? a) A bounding distal pulse b) Acute pain c) Ecchymosis of the surrounding skin d) Increasing edema
d) Increasing edema
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Jugular venous distention b. Right upper quadrant pain c. Pitting edema of the lower legs d. Shortness of breath while lying down
d. Shortness of breath while lying down
